Provider Demographics
NPI:1982055687
Name:PENK, DAVID PATRICK (MS, QMHP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:PATRICK
Last Name:PENK
Suffix:
Gender:M
Credentials:MS, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 516
Mailing Address - Street 2:11020 STATE ROUTE 250
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439
Mailing Address - Country:US
Mailing Address - Phone:618-943-3754
Mailing Address - Fax:618-943-3657
Practice Address - Street 1:11020 STATE ROUTE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-3657
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376006178Medicaid
IL376006178Medicaid
ILC48402Medicare UPIN